F O R M
APPLICATION FORM FOR FAMILY BENEFIT SCHEME.
District:- Municipality/Town Committee
Village/ Panchayat/ Ward/ House No.
3 Name of Father/ Husband:-
4 Categories:- SC/ST (H) (P)/Woman/Landless/
5 Full Address :-
6 Name of deceased:-
7 Certificate from the local panchayat to the effect that the deceased was the principal bread earner and has living below the poverty line.
8 Relationship with the deceased:-
9 date of death of the deceased:-
10 Whether Death certificate is enclosed:-
11 Declaration:- I solemnly affirm that:-
a. I do not have any family income of Rs.11,000/- per annum or more.
b. I am a resident of …………………………………....(District/State)
c. I have not applied previously for grant of relief under the National
Family Benefit Scheme.
d. I declare that the information furnished in this application is true and
Correct to the best of my knowledge and belief.
Signature or Thumb impression
of the applicant.
(To be filled up by the enquiry authority)
Results of preliminary enquiry by the village/panchayat
Municipality Board/ Town Committee.
Signature of verifying person
Gaon Panchayat/ President/ Chairman
Town Committee/ Chairman Municipality Board.
Date:- Full Address:-
Note:- This application should be sent with full particulars to the Deputy Commissioner of the concerned district.
Remarks of the Deputy Commissioner.